Avoiding frenotomies and improving health equity: Findings from a paradigm shift newborn feeding difficulties model

Abstract

Importance: Newborn feeding difficulties are increasingly attributed to ankyloglossia, leading to a surge in frenotomy procedures despite limited high-level evidence supporting its effectiveness. Disparities in access to appropriate feeding assessments contribute to potential surgical overtreatment and inequities in care.

Objective: To evaluate the impact of a paradigm shift newborn feeding difficulties model on clinical care patterns and health equity.

Design, setting, and participants: A retrospective cohort study of infants (<6 months) with ankyloglossia-related ICD-9/ICD-10 codes at a tertiary academic pediatric hospital's otolaryngology outpatient clinic between 2017 and 2024, comparing pre-model (2017-2023) and post-model (2023-2024) cohorts.

Main outcomes and measures: Primary outcomes included certified speech-language pathologist (SLP) and lactation consultant (CLC) evaluations, ear, nose, and throat (ENT) visits, and frenotomy rates. Sociodemographic disparities in access and treatment were analyzed using multivariable logistic regression and mediation analysis.

Results: Of 1454 patients, 1171 were pre-model and 283 were post-model. Post-model patients were older (5.3 vs. 3.6 weeks, P < 0.001), more likely to have public insurance (34.3% vs. 27.4%, P = 0.02), and had increased SLP/CLC visits (50.9% vs. 0.9%, P < 0.001), reduced ENT visits (61.8% vs. 99.7%, P < 0.001), and decreased frenotomy rates (17.7% vs. 45.4%, P < 0.001). Pre-model patients were also less likely to receive frenotomy if had non-English language (AOR: 0.34; p = 0.001) and public insurance (AOR: 0.56; p = 0.002); for post-model patients, these disparities were not present. Mediation analysis indicated that the model mitigated the negative effect of public insurance on SLP/CLC access by 54%.

Conclusions and relevance: Implementing a paradigm shift newborn feeding difficulties model resulted in a significant shift in clinical care patterns, with increased utilization of SLP/CLC services and reduced frenotomies. The model also improved access to care for publicly insured patients, demonstrating its potential to enhance health equity and optimize feeding difficulty management.

Keywords: Ankyloglossia/tongue-tie management; Certified lactation consultant; Frenotomy; Health equity; Multidisciplinary newborn care coordination; Newborn feeding difficulties; Speech-language pathology.